ICD 10 Coding Alert

Question: A 75-year-old new patient came into our pulmonology office complaining of a harsh dry cough, shortness of breath (SOB), and fatigue. After a physical examination and patient history, the pulmonologist ordered a two-view chest X-ray, which revealed lung nodules. During the history, the patient revealed they used to work as an auto mechanic for large trucks. The physician diagnosed the patient with graphite fibrosis of the lung and prescribed them a bronchodilator to help open the airways.

How would I report this encounter?

New Mexico Subscriber

Answer: You’ll use two CPT^® codes and one ICD-10-CM code to report this encounter. The new patient presented with a new condition, the physician ordered chest X-rays, and prescribed the patient a bronchodilator at the end of the visit. These factors fulfill the requirements for a moderate level of medical decision making (MDM), which means you’ll assign 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.) to report the evaluation and management (E/M) visit.

Important: Since the physician is reporting the chest X-rays separately, you won’t be able to factor them into determining the level of MDM when choosing your E/M code.

The two-view chest X-ray will be reported using 71046 (Radiologic examination, chest; 2 views). According to the CPT^® guidelines, the X-ray images need to be permanently recorded and included in the patient record along with a formal report of interpretation.

Lastly, you’ll assign J63.3 (Graphite fibrosis (of lung)) to report the patient’s diagnosis if this can be confirmed at the time of the visit. Otherwise, you will just report the patient’s symptoms, such as:

• R05.- (Cough)
• R06.02 (Shortness of breath)
• R53.83 (Other fatigue)

Pulmonary fibrosis is a condition where the patient’s lung tissues become scarred over time. In this case, the patient has developed graphite fibrosis of the lungs, which is where small particles of graphite have collected in the lungs over years of exposure.